corticosteroid therapy in neonates undergoing cardiopulmonary bypass

Conditions: Congenital Heart Disease; Disorder of Fetus or Newborn

Summary: although cardiopulmonary bypass (heart-lung machine) is a necessary component of heart surgery, it is not without consequences. cardiopulmonary bypass initiates a potent inflammatory response secondary to the body's recognition of the abnormal environment of the heart-lung machine. this inflammatory response may lead to poor heart, lung and kidney function after the heart surgery. this is turn can lead to longer times on the ventilator (breathing machine), the need for higher doses of heart medications, a longer stay in the intensive care unit and even death. this is particularly true in infants less than one month of age due to their size and the immaturity of their organs. the appreciation of the post-cardiopulmonary bypass inflammatory response has resulted in a number of interventions directed at its reduction. no therapy has been recognized as the standard of care; however steroid therapy has been applied most often despite unclear evidence of a benefit. this study aims to determine if steroids improve the outcomes of babies undergoing heart surgery.

this study is a multi-institutional randomized double-blind placebo controlled trial of the use of glucocorticoids to improve the clinical course of neonates following cardiac surgery. cardiopulmonary bypass (cpb) is critical to cardiac surgery, but the pathophysiologic processes engendered by cpb play an important role in post-operative recovery. the use, doses and schedule of glucocortiocoid administration to ameliorate these cpb induced processes is highly variable and without clear data to provide direction. the primary aim of this study is to compare the effects of intraoperative methylprednisolone to placebo on a composite morbidity-mortality outcome following neonatal cpb. secondary endpoints include: inotropic requirements, incidence of low cardiac output syndrome, fluid balance, icu stay parameters, levels of inflammatory molecules, neuro-developmental outcomes, and safety parameters. the study will focus on neonates because their post-cpb clinical course is typically more severe, and that high level of severity itself provides a substrate for identifying the positive effects of a particular therapy. finally, a therapy identified as beneficial has the greatest potential for benefit in this vulnerable population

Eligibility criteria:
inclusion criteria: * age \< 1 month * male and female patients who are scheduled to undergo cardiac surgery involving cpb exclusion criteria: * prematurity: \< 37 weeks post gestational age at time of surgery * treatment with intravenous steroids within the two days prior to scheduled surgery. * participation in research studies involving the evaluation of investigational drugs within 30 days of randomization. * suspected infection that would contraindicate steroid use (eg - herpes) * known hypersensitivity to ivmp or one of its components or other contraindication to steroid therapy (eg - gastrointestinal bleeding). * preoperative use of mechanical circulatory support or active resuscitation at the time of proposed randomization.

Keywords: cardiopulmonary bypass (cpb) system inflammatory response inflammation methylprednisolone neonates steroid cardiac surgical procedures children infants pediatrics glucocorticoid heart disease heart defects, congenital cardiovascular diseases cardiovascular abnormalities corticosteroid methylprednisolone hemisuccinate hormones physiological effects of drugs randomized clinical trial